DEDICATION :

CONTENTS :

Definition of Infertility :

Definition of Infertility The couple has not conceived after 12 months of contraceptive-free intercourse if the female is under the age of 34. 12 months is the lower reference limit for Time to Pregnancy (TTP) by the World Health Organization.1
Or
The couple has not conceived after 6 months of contraceptive-free intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy as when to seek medical intervention
References
Makar RS, Toth TL (2002). "The evaluation of infertility". Am J Clin Pathol. 117 Suppl: S95–103. PMID 14569805.

Blood –testes barrier :

Blood –testes barrier

Slide 23:

Spermiogenesis

Sperm :

Sperm

Slide 25:

sperm
55-65 µm in length
Three parts head, neck and tail. On the outside of the anterior two thirds of the head is a thick cap called the acrosome that is formed mainly from the Golgi apparatus.
It contains enzymes similar to those found in lysosomes hyaluronidase and powerful proteolytic enzymes. These play important roles in allowing the sperm to enter the ovum and fertilize it.

Sperm :

Sperm The tail of the sperm, called the flagellum, has three
major components:
(1) A central skeleton constructed of 11 microtubules, collectively called the axoneme
(2) A thin cell membrane covering the Axoneme
(3) A collection of mitochondria surrounding the axoneme in the proximal portion of the tail (called the body of the tail)
Normal sperm move in a fluid medium at a velocity
of 1 to 4 mm/min.

SPERM TRANSPORTATION :

SPERM TRANSPORTATION

Sperm motility :

Sperm motility Grading is as follows:
Grade 0 is no movement,
Grade 1 is sluggish movement,
Grade 2 is slow movement but not straight,
Grade 3 is movement in a straight line, and
Grade 4 is terrific speed.
Patients with abnormal motility should be evaluated for pyospermia, antisperm antibodies, varicocele, sperm ultrastructural abnormalities, or partial ductal obstruction.

POST TESTICULAR :

POST TESTICULAR OBSTRUCTIVE
Epididymal
Vasal
EPIDIDYMAL HOSTILITY
ACCESSORY GLAND INFECTION
Prostitis
Seminal vesiculitis
IMMUNOLOGIC
Post vasectomy
Idiopathic
Infertility is also thought to be passed on to the son from the father.

LOCAL EXAMINATION :

Semen analysis :

Semen analysis

Gland Approximate %Description :

Gland Approximate %Description Testes
2-5%Approximately 200- to 500-million spermatozoa produced in the testes, are released per ejaculation.
seminal vesicle
65-75%amino acids, citrate, enzymes, flavins, fructose (the main energy source of sperm cells, which rely entirely on sugars from the seminal plasma for energy), phosphorylcholine, prostaglandins (involved in suppressing an immune response by the female against the foreign semen), proteins, vitamin C
Prostate
25-30%acid phosphatase, citric acid, fibrinolysin, prostate specific antigen, proteolytic enzymes, zinc (serves to help to stabilize the DNA-containing chromatin in the sperm cells. A zinc deficiency may result in lowered fertility because of increased sperm fragility. Zinc deficiency can also adversely affect spermatogenesis.)
bulbourethral glands
< 1%galactose, mucus (serve to increase the mobility of sperm cells in the vagina and cervix by creating a less viscous channel for the sperm cells to swim through, and preventing their diffusion out of the semen. Contributes to the cohesive jelly-like texture of semen.), pre-ejaculate, sialic acid

Semen analysis :

Semen analysis It is not measure of fertility. One source states that 30% of men with a normal semen analysis actually have abnormal sperm function 1
An abnormal test suggest likelihood of decreased fertility.
There are certain limits below which it is not statistically possible to initiate pregnancy.
Of these sperm count and motility correlate best with fertility.
"Understanding Semen Analysis". Stonybrook, State University of New York. 1999. http://www.uhmc.sunysb.edu/urology/male_infertility/SEMEN_ANALYSIS.html. Retrieved 2007-08-05

Semen collection :

Semen collection Period of exual abstinence 48-72 hours. why ?
Sperm motility tends to fall when abstinence period is more then 5 days.
2 semen analysis
Self stimulation,coitus interuptus(less ideal), special condoms.
Analysis within one hour.
During transit body temperature.

Computer-aided semen analysis (CASA) :

Computer-aided semen analysis (CASA) Apart from previous mentioned,CASA can detect:
curvilinear velocity, defined as the average distance per unit time between successive sperm positions.
The straight-line velocity, which is the speed of forward direction.
linearity, which is the straight-line velocity divided by the curvilinear velocity
for research purposes.

Radiological testing :

Testicular biopsy :

Testicular biopsy Azoospermic men
with a normal-sized testis and normal fTindings on hormonal studies ;
To evaluate for ductal obstruction,
To further evaluate idiopathic infertility, and
To retrieve sperm.
Relative indications
For testicular biopsy include ruling out partial obstruction in patients with severe oligospermia.
Evaluating patients with hypogonadotropism to select those likely to respond to gonadotropin replacement, and
Retrieving spermatozoa in azoospermic patients undergoing IVF or ICSI

Treatment :

Treatment

Assess Expectations for Male Infertility Treatment :

Assess Expectations for Male Infertility Treatment What treatments were previously recommended? Were they followed correctly? What results were obtained?

GENERAL TREATMENT :

GENERAL TREATMENT :

GENERAL TREATMENT Diet
A diet high in antioxidants such as vitamin C and vitamin E has been proposed to improve the quality of sperm by decreasing the number of free radicals that may cause membrane damage.
Additionally, the use of zinc, fish oil, and selenium has been shown to be of benefit in some studies.
Activity
Patients should limit the use of potentially spermatotoxic substances such as cigarettes, marijuana, and anabolic steroids. Environmental exposures to harmful substances and/or conditions should be minimized.
The optimal timing to perform intercourse for conception is every 2 days at mid cycle.
The use of spermatotoxic lubricants should be avoided.

Methods of sperm retrieval :

Methods of sperm retrieval MESA
PESA
TESE
TESA

IVF with Embryo Transfer :

IVF with Embryo Transfer Egg and sperm are retrieved from couple, donor(s), or both Combined in a petri dish, incubated for 2–5 days If fertilization and cleavage occurs, embryo is transferred through a catheter to uterus

Gamete Intra-Fallopian Transfer(GIFT) :

Gamete Intra-Fallopian Transfer(GIFT) A mixture of a woman’s eggs and sperm are placed into the fallopian tube during a laparoscopy.
Once inserted, fertilization is allowed to occur.

Zygote Intrafallopian Transfer (ZIFT) :

Zygote Intrafallopian Transfer (ZIFT) Combines techniques used in IVF and GIFT Ova are placed in a petri dish with sperm If fertilization occurs, the zygote:
Is injected into fallopian tube
Travels through tube to uterus
Implants in uterus

Zygote Intra-Fallopian Transfer(ZIFT) :

Zygote Intra-Fallopian Transfer(ZIFT) Mixture of In Vitro Fertilization and Gamete Intra Fallopian Transfer.
Fertilization takes place outside the uterus and placed into the fallopian tubes.

Cryopreservation :

Cryopreservation Sperm or embryos are preserved by freezing for replacement in subsequent cycles Photo source: http://www.dcmsonline.org

Intracytoplasmic Sperm Injection (ICSI) :

Intracytoplasmic Sperm Injection (ICSI) A single sperm is injected directly into the cytoplasm of the oocyte
Increases probability of fertilization

Slide 106:

Hyaluronan Acid Binding by Human Sperm:
Assessment of sperm function and sperm selection for ICSI Only live and mature motile sperm will bind to Hyaluronan The sperm plasma membrane need to be incorporated with Hyaluronan and Zona binding receptors

Selecting an ART Program :

Selecting an ART Program Qualifications and experience of the clinic and its personnel.
Support services available
Cost
Success rates of that specific program

Conclusion :

Conclusion Male infertility is multifactorial
Hormones, physiology, environment, anatomy and DNA all play a role
It is the delicate balance of all of these factors that must be weighed in order to optimize male fertility
Every evaluation is different and every treatment strategy is geared toward the individual patient and circumstance and must always take into account the female partner